For Students: Reasonable Accommodation Request Form

This online request form can only be used by students who have already met with SDS staff and been approved for accommodations. It is not to be used by students making an initial request for accommodations who have not yet met with and been approved by SDS staff.

Please be sure to fully complete the form below and submit it to SDS staff for review and consideration. Required fields are marked with a red asterisk *.

Personal Information

First Name: *Last Name: *

MIT ID: *

Term Address:

DormFSILG

Phone:

Email: *

Academic Advisor:*

Department/Major: *

Select Student Type*:

Term and Year of Entry:*

Year of Graduation:*

Accomodation Request 1

Please provide a detailed description of the accommodation(s) you are requesting (Note: Disabilities Services must be given a reasonable amount of time to respond to an accommodation request.)

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Accomodation Request 2

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Accomodation Request 3

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Accomodation Request 4

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Accomodation Request 5

Course Name:

Course Number:

Days/Times:

Instructor:

Instructor Email:

Accommodation Request:

Other Accommodations

Please list any other accommodations you may be requesting for extracurricular activities, events, or campus activities.

I am hereby requesting a reasonable accommodation for my disability. I grant permission to the Disability Coordinator and individuals identified by the Coordinator as necessary participants in the decision-making process (instructors, academic advisors, Medical Department staff, etc.) to review the pertinent information I have provided and discuss the matter with me and my health professional(s). If accommodations are not clearly identified in a diagnostic report, the Disability Coordinator can seek outside, professional clarification.

In general, Institute policy calls for reasonable accommodations to be made for students with disabilities on an individualized and flexible basis. It is the responsibility of students with disabilities, however, to seek available assistance at MIT and to make their needs known.

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